Vital Information

Important Information for Completing the Death Certificate and Disposition Permit

The following questions are necessary for the funeral director to accurately complete the death certificate and/or burial/cremation permit. These are legal documents that require precise and correct information.

If you are unsure of an answer, you may skip it for now. However, please note that the information will likely be required to successfully file the death certificate. The state typically does not issue death certificates with fields marked as "unknown."

We understand how difficult this process may be, and we are committed to being patient and empathetic. This document can be completed online or in person with the funeral arranger—whichever option is most comfortable for you.

Please let us know how we can assist you during this time.
Name of Decedent

PrefixFirst NameMiddle NameLast NameSuffix
Decedent's Sex

MaleFemaleother
Decedent's Social Security Number
Did the decedent serve in the US Armed Forces?
Age of deceased
Date of birth

YearMonthDay
Date
Place of birth
Date of death

YearMonthDay
Date
Place of death
Was Decedent a LACC Case? If yes, please provide case number:
Decedent’s physical address (No P.O. Boxes)

Street Address

Street Address Line 2

City, CountyState

Zip Code
Homeless Decedent’s with mailing address only

Street Address

Street Address Line 2

City, CountyState

Zip Code
Name of attending physician, or primary care doctor

First NameLast Name
Fathers full name

PrefixFirst NameMiddle NameLast NameSuffix
Mothers full name (including maiden)

First NameLast NameSuffix
Was Decedent of Hispanic origin?

NoMexican/Mexican AmericanPuerto RicanCubanOther
Decedent's Race

WhiteBlack or African AmericanAsian IndianChineseKoreanFilipinoJapeneseAmerican Indian or Alaska NativeVietnamesePacific IslanderOther
Decedent's highest level of education
Usual occupation during most of working life.
Kind of business / industry
Marital Status
Last name of decedent at birth (Maiden name)
Decedent’s Spouse's Maiden name

PrefixFirst NameMiddle NameLast NameSuffix
Spouse's address if different than decedent's

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Your Name (Next of Kin, Informant to State)

First NameLast Name
What is the informant's relationship to the decedent?
Informant's address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Informant's mobile phone number

Area CodePhone Number
Email address of informant
example@example.com
Final Disposition of decedent
Name of cemetery
Are there any individuals having greater or equal authority to the right of disposition than the informant? If so please list them below.
We extend our deepest condolences during this difficult time. Please know that we are here to support you in honoring and remembering your loved one.

To assist with identification and viewing arrangements, we kindly ask that you provide the most recent photo of your beloved. You may upload a photo or a valid ID below for reference.

If you have any questions or need further assistance, please do not hesitate to reach out.
Please upload a photo of decedent
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We are available 24 hours a day, 7 days a week

If you have any questions please reach out at Arrangementsbycelestina@gmail.com
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